HOT TOPICS                             in              Primary Care A National Conference For NPs, MDs, PAs, CNMs, and RNs...
Highlights and Benefits                                            Accreditation                                          ...
Jackson Hole, WYS   ummer in Jackson Hole – breathtaking in beauty,    back-country solitude, western ambience – offers an...
Conference Faculty                                                 Conference ScheduleB. Joseph Guglielmo, PharmD         ...
Tuesday, July 31                                                Wednesday, August 1Choose one topic in each time period an...
Registration Information	 Registrations must include full tuition payment to be accepted. Registrations faxed without pay...
Hotel Accommodations                                                    Travel Discounts	 The conference will be held at ...
Please Post Prominently or Forward to a Colleague if Unable to Attend                                                     ...
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Hot Topics in Primary Care

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Hot Topics in Primary Care

  1. 1. HOT TOPICS in Primary Care A National Conference For NPs, MDs, PAs, CNMs, and RNs Jackson Hole, WY July 29 – August 1, 2012 Home of the Grand Tetons & Gateway to YellowstoneREGISTER TODAY! In Partnership with:Earn up to 17.5 hourswww.ContemporaryForums.comwww.onlineCElibrary.com
  2. 2. Highlights and Benefits Accreditation A Certificate of Attendance will be available online after youIn the current environment of health promotion and disease complete the course requirements.prevention, primary care is in the spotlight. The rationaluse of diagnostic tests and new medications, reduction Nurses and Nurse Practitionersof cardiovascular risk factors, issues in women’s healthand pediatric care, behavioral approaches for a healthier Contemporary Forums is accredited as a provider ofoutcome, and management of chronic disease, all combine continuing nursing education by the American Nursesas mandates as we move forward in the 21st century. We all Credentialing Center’s Commission on Accreditation.know the aging population will put incredible demands on This activity is approved for 17.5 contact hours.the current health care system. What can we do to prepare Contemporary Forums is approved by the California Boardfor this challenge? of Registered Nursing, Provider #04516. This activity isDesigned for NPs, MDs, PAs, CNMs, and RNs from primary approved for 21 contact hours.care settings, Hot Topics in Primary Care will focus on (CA BRN contact hour = 50 minutes)collaborative approaches for these and other clinical careissues. Sponsored by Contemporary Forums, a leader in Physiciansquality continuing education, in partnership with JNP:The Contemporary Forums is accredited by the AccreditationJournal for Nurse Practitioners, this conference brings together Council for Continuing Medical Education to providean outstanding panel of clinically active faculty members who continuing medical education for physicians. Contemporarywill discuss the challenges you face daily in your office or Forums designates this Live Activity for a maximum ofclinic setting. Highlights of the conference include: 17.5 AMA PRA Category 1 CreditsTM. Physicians should A number of “Hot Topics” you deal with in your every claim only the credit commensurate with the extent of their day practice, addressed in a variety of teaching styles participation in the activity. including didactic sessions, faculty panels, concurrent Application for CME credit has been filed with the American sessions, and interactive case study discussions. Academy of Family Physicians. Determination of credit is An emphasis on prevention as we look at evidence- pending. based approaches for managing chronic and acute Nurse-Midwives health problems. The Continuing Education Committee of the American A comprehensive approach to primary care, including College of Nurse-Midwives grants reciprocity status to topics on pediatrics, women’s health, pharmacology, the Accreditation Council for Continuing Medical Education and geriatrics. (ACCME) for Category 1 offerings, providing the program The glorious setting of Jackson Hole and the Grand is relevant to nurse-midwifery. A maximum of 17.5 hours Tetons, where you can combine outstanding education may be reported. with time to explore this incomparable setting. Physician AssistantsBring your questions and puzzling cases…this dynamicfaculty will give you answers and guidance. Plan now to The American Academy of Physician Assistantsjoin your colleagues at Hot Topics in Primary Care! accepts Category 1 CME approval from organizations accredited by the ACCME to grant Category 1 hours toward the Physician’s Recognition Award. PAs may report up to Who Should Attend? 17.5 hours of credit. Pharmacology Credit for Prescriptive Authority Family, Adult, Geriatric,  Nurse-Midwives A maximum of 9.5 hours in pharmacology may be earned and Women’s Health  Office and Clinic Staff Nurses by attending this conference. indicates sessions with Nurse Practitioners … and anyone else interested pharmacology content. Because states’ requirements vary, Family Physicians contact your Board of Nursing for more information. in providing state-of-the-art, Internists comprehensive primary care Physician Assistants2 Visit us at www.ContemporaryForums.com to register today • Follow us on Facebook and Twitter (#HTPC12)
  3. 3. Jackson Hole, WYS ummer in Jackson Hole – breathtaking in beauty, back-country solitude, western ambience – offers anexperience unmatched anywhere else. Set in the shadow You may want to extend your stay to tour Yellowstone – our country’s first national park and largest outside of Alaska. Visiting Yellowstone is a unique opportunity to see a wideof the towering Grand Teton Mountains, Jackson Hole variety of wildlife – including moose, elk, buffalo, deer,is a unique blend of Old West charm and cosmopolitan eagles and maybe even a bear!atmosphere. Within its confines lie Grand Teton National Our conference site, the Snow King Resort, has a variety ofPark, the National Elk Refuge and the friendly town of activities and entertainment. Swim in the heated pool, relaxJackson. in the jacuzzi or take the chairlift to the top of Snow KingThe Grand Tetons may be the world’s greatest range of Mountain to enjoy the view of the valley and the Tetons.mountains to behold—majestic by day, mysterious by night; And, there’s plenty of action for kids, too. Speed down thepurple-pink at dawn, slate-blue at dusk; sometimes misty, Alpine Slide, challenge someone to a game of minigolf, orsometimes clear, but always trimmed by snow. Enjoy a hike ride horseback up Snow King Mountain.on one of the clearly marked trails and capture the dazzling With such a wide array of beautiful scenery and excitingarray of wild flowers and prolific wildlife, or venture deep activities, you won’t want to miss this opportunity to visitinto the back country for a close-up of the stunning peaks the spectacular area of the Grand Tetons and Yellowstoneof the Grand Tetons. during this conference. Bring your family and friends … it’llThe conference schedule has been arranged to allow time be a trip like no other!to enjoy the activities of the area. You may choose a scenic Websites to Visit:float trip down the Snake River or thrill to a whitewater • jacksonholechamber.com • grand.teton.national-park.comadventure through one of its canyons. Golf, horseback • gtmf.org • jacksonholetraveler.comriding, mountain biking, jeep tours, and fly fishing are just a • yellowstonenationalpark.com • snowking.comfew of the other activities you can enjoy.If you still have the energy after an active day, kick up yourheels western style to live entertainment at the MillionDollar Cowboy Bar or attend the action-packed Jackson Area ActivitiesHole rodeo. Over 40 restaurants in Jackson Hole offer Listed below are some of the many activities availablemenus to suit all tastes from delicious prime rib in the lively in the Jackson Hole area. The Activities Coordinatoratmosphere of the Mangy Moose to wild game at the Gun at the Snow King Resort will mail activity descriptions,Barrel Steak and Game House. Experience the authenticity details, pricing and advance activity reservation forms toof a Paris bistro at Rendezvous Bistro, a locals’ favorite, or all registrants before the conference.the creative cuisine and upscale atmosphere of the BlueLion or Snake River Grill. And for an unequaled view and Whitewater River Rafting Grand Teton National Park Tourexquisite dining experience, don’t miss The Granary. Wild West Jeep Tour Hot Air Balloon Rides Scenic Float Trip on Snake River Jackson Hole RodeoThe arts also flourish in Jackson Hole. Enjoy the nightly Boat/Kayak Rentals Grand Teton Music Festivalconcerts of the Grand Teton Music Festival. There are Yellowstone Park Tour (Lower Loop) Horseback Ridingnumerous art galleries displaying the works of a number Wildlife Expeditions Hang Gliding Ridesof well-known artists. And you won’t want to miss the Covered Wagon Cookout and Show Guided Fishing TripsNational Museum of Wildlife Art, situated on a dramatic cliff Guided Hiking and Biking Toursoverlooking the National Elk Refuge. RAVE REVIEWS! “The conference exceeded my expectations. A highly “I was very impressed with the speakers and topics. I informed faculty presented information that was also appreciated having time to enjoy the Jackson Hole rich with substantive detail within a common sense area. I encourage all clinicians to attend!” clinical framework. All of this was accomplished with Jean M. Styvaert, ARNP • Bettendorf, IA interesting and often entertaining presentation styles “The quality of the presenters is what attracts me every and ... in the beautiful setting of the Grand Tetons!” time to come back. Cool weather and the National JoAnn Johnson, MD • St. Paul, MN Parks do the rest!” “I truly believe this was one of the best conferences I Barbara Barylska, MD • Peachtree City, GA have attended for continuing ed and I’ve been out of school 15 years. Thanks so much.....GREAT speakers.” Sharon Schlick, PA-C • Perry, FL A Leader in Quality Continuing Education for Healthcare Professionals for 30 years 3
  4. 4. Conference Faculty Conference ScheduleB. Joseph Guglielmo, PharmD Saturday, July 28Professor and ChairDepartment of Clinical Pharmacy 3:30 – Registration • Welcome ReceptionUniversity of California San Francisco 5:30 p.m.Associate Director, Pharmaceutical ServicesUCSF Medical CenterSan Francisco, California Sunday, July 29Nancy Nadolski, MSN, MEd, FNPClinical Director, Insomnia Medicine 7:00 a.m. RegistrationSt. Alphonsus Regional Medical Center Continental Breakfast for Conference ParticipantsAdjunct Faculty, MSN/NP ProgramIdaho State University 8:00 Strategies for Prevention ofBoise, Idaho Coronary Heart Disease Karol E. Watson, MD ( = .25 hr.)Jeffrey Wallace, MD, MPHProfessor and Director of Clinical Geriatrics 8:45 New Approaches for Treating InsomniaUniversity of Colorado Health Sciences Center Nancy Nadolski, MSN, MEd, FNP ( = .5 hr.)Denver, Colorado 9:30 Refreshment BreakKarol E. Watson, MDAssociate Professor of Medicine and Cardiology 10:00 Antimicrobial Management of OutpatientCo-Director of Preventive Cardiology Respiratory Tract InfectionUniversity of California Los Angeles B. Joseph Guglielmo, PharmD ( = .5 hr.)Los Angeles, California 10:45 Understanding Atrial Fibrillation: MoreVictoria Weill, MSN, CPNP-PC Common Than Ever in the Aging PopulationAssociate Program Director Karol E. Watson, MD ( = .25 hr.)Pediatric Nurse Practitioner Program 11:30 Dispelling Contraceptive Myths:University of Pennsylvania School of Nursing A Case-Based ApproachPhiladelphia, Pennsylvania Justine P. Wu, MD, MPH ( = .75 hr.)Pediatric Nurse PractitionerNorth Penn VNA Children’s Clinic 12:15 p.m. Questions and DiscussionLansdale, Pennsylvania Faculty Panel ( = .25 hr.)Justine P. Wu, MD, MPH 1:00 AdjournClinical Assistant Professor of MedicineUMDNJ-Robert Wood Johnson Medical SchoolNew Brunswick, New Jersey Monday, July 30 Conference Objectives 7:00 a.m. Continental Breakfast for Conference Participants 8:00 Test Your Skills: Dermatologic Conditions in ChildrenThis program will enable the experienced clinician to better: Victoria Weill, MSN, CPNP-PC ( = .25 hr.) Explore diagnostic and management options for a variety of conditions seen in the office or clinic 9:00 Managing Hyperlipidemia: setting, including hyperlipidemia, pediatric dermatologic What’s New in the New Guidelines? conditions, abnormal pap tests, atrial fibrillation, cognitive Karol E. Watson, MD ( = .5 hr.) impairment, infectious disease and mood disorders. 9:45 Refreshment Break Develop strategic approaches for managing patients 10:15 Women with Chronic Medical Conditions: with chronic conditions such as chronic pain, insomnia, Can We Provide Highly Effective aging issues, and contraception for women with chronic Contraception That Is Also Safe? medical conditions. Justine P. Wu, MD, MPH ( = .75 hr.) Discuss appropriate pharmacologic management for 11:00 Assessment of Cognitive Impairment: selected infectious conditions. Pearls for Practice Synthesize and apply new knowledge through case- Jeffrey Wallace, MD, MPH based discussion of select clinical challenges. 11:45 What Is the Impact of CA-MRSA in the Collaborate with other colleagues on the health care Management of Skin and Soft Tissue Infection? team to maximize patient outcome. B. Joseph Guglielmo, PharmD ( = .5 hr.) 12:30 p.m. Questions and Discussion Faculty Panel ( = .25 hr.) 1:00 Adjourn4 Visit us at www.ContemporaryForums.com to register today • Follow us on Facebook and Twitter (#HTPC12)
  5. 5. Tuesday, July 31 Wednesday, August 1Choose one topic in each time period and note your 7:00 a.m. Continental Breakfast for Conference Participantsselection on the Registration Form. 8:00 Immunizations for Kids: Update 2012 7:00 a.m. Continental Breakfast for Conference Participants Victoria Weill, MSN, CPNP-PC ( = .75 hr.) 8:00 CONCURRENT SESSIONS #1 8:45 Update in the Management of Abnormal Paps: Avoiding Overscreening and Overtreatment #11 Contemporary Approaches Justine P. Wu, MD, MPH for Managing Hypertension Karol E. Watson, MD ( = .5 hr.) 9:30 Questions and Discussion Faculty Panel #12 Pneumonia in Children: New Guidelines for Management 9:45 Refreshment Break Victoria Weill, MSN, CPNP-PC ( = .5 hr.) 10:00 Men’s Health: Interesting Cases 9:00 Session Change Jeffrey Wallace, MD, MPH ( = .25 hr.) 9:15 CONCURRENT SESSIONS #2 10:45 Mood Disorders: Assessment and Management of Depression and Anxiety #21 New Concepts in the Antibacterial Nancy Nadolski, MSN, MEd, FNP ( = .5 hr.) Treatment of UTI B. Joseph Guglielmo, PharmD ( = .75 hr.) 11:30 Prescribing for the Older Adult: Practical Tips and Potential Pitfalls #22 Everything Seems So Normal: Identifying Jeffrey Wallace, MD, MPH ( = .75 hr.) Substance Abuse Problems in Your Patients Nancy Nadolski, MSN, MEd, FNP ( = .5 hr.) 12:15 p.m. Questions and Discussion Faculty Panel ( = .25 hr.)10:15 Refreshment Break 12:45 Adjourn10:45 CONCURRENT SESSIONS #3 #31 Health Promotion and Disability Prevention = Pharmacology for Advanced Practice Clinicians in Older Adults Jeffrey Wallace, MD, MPH #32 Challenging Cases in Pediatric Primary Care Interested in Being Published? Victoria Weill, MSN, CPNP-PC ( = .5 hr.) Submit Your Work!11:45 Session Change JNP: The Journal for Nurse Practitioners12:00 p.m. CONCURRENT SESSIONS #4 is looking for articles on the following topics:  Women’s Health #41 Managing Chronic Pain:  Diabetes Management Useful Tools and Approaches  Dermatology Nancy Nadolski, MSN, MEd, FNP ( = .5 hr.)  Cardiovascular Disease  Obesity #42 Miscarriage Management: Shifting Care Out  Care of the Older Adult of the ER and into the Primary Care Setting  Psychiatric/Mental Health Justine P. Wu, MD, MPH ( = .25 hr.) For more information on submitting your work to 1:00 Adjourn JNP: The Journal for Nurse Practitioners, visit ees.elsevier.com/jnp or www.npjournal.org. A Leader in Quality Continuing Education for Healthcare Professionals for 30 years 5
  6. 6. Registration Information Registrations must include full tuition payment to be accepted. Registrations faxed without payment will not be processed. Conference communications are sent via email. When registering please provide attendee’s best email address as some emails are filtered and blocked. Since conference registration and hotel rooms are limited, early registration is advised. Out of consideration to registrants, children of any age and spouses may not attend the sessions. Tuition (U.S. Funds) NPs, PAs, CNMs, RNs, Residents,**Others Physicians Early Registration Fee* (On/Before June 18) $495 $595 Regular Registration Fee $545 $645 (After June 18)* Postmarked or phone/fax/online registration and fees received on/before June 18.** Residents: To qualify, submit facility verification of status with registration.Your tuition includes a complimentary subscription to JNP: The Journal for Nurse Practitioners, the Welcome Reception, daily ContinentalBreakfast, Certificate of Attendance, and Online CE Library access to presentation handouts before and after the conference. Group Discounts (Mail, fax or call in together. Online registration is not available.) Tuition discounts are given to groups of 3 or more registering for the complete conference. To qualify for the group discount, all registration information must be complete for all group members, payment included and forms sent together. If faxing, list all group members on cover sheet. Subtract the discount from the tuition fee. Groups may not be formed after individual registrations are received. $25 per person discount for 3 or 4 in a group $45 per person discount for 5 or more in a group Method of Tuition Payment Make payment by check (payable to Contemporary Forums and enclose with Registration Form), Visa, MasterCard, Discover, American Express or Purchase Order. A $30 fee is charged for any returned check. Personal checks are NOT accepted at the conference. Purchase Orders must be received with registration by the conference date and include the P.O. number, invoice address, tuition, approval signature, contact name, email address and phone number. Register Online, or by Phone, Fax or Mail (Payment is required to register.) Register only ONCE, online at www.ContemporaryForums.com, by mail or fax (800) 329-9923, or call (800) 377-7707, Monday-Friday, 8 a.m. - 5 p.m. (Pacific Time). Before calling, complete all registration information. Tax Deductibility Expenses of training, tuition, travel, lodging and meals to maintain or improve professional skills may be TAX DEDUCTIBLE. Consult your tax advisor. Partial Attendance (Online registration is not available.) Call Contemporary Forums for tuition and CE credit for individual days. Group discounts do not apply. Registrations may not be shared. Cancellations Cancellations may be made by phone or in writing. Cancellations received on/before June 18 receive a full tuition refund. Cancellations received after June 18 are assessed a $20 processing fee. No refunds for cancellations received after the conference begins or for “no shows.” If this meeting is cancelled for any reason, including labor strikes or acts of God, liability is limited to a full refund of registration fees. Program Changes Contemporary Forums reserves the right to make necessary changes in speakers, topics or schedule. The most current program can be found on our website. Questions? Contact Contemporary Forums at (800) 377-7707, Monday - Friday, 8 a.m. - 5 p.m. (Pacific Time) or email info@cforums.com. If you require special arrangements at this conference, call (800) 377-7707, at least 30 days prior to the conference.EASY WAYS TO REGISTER Online (Credit card only) Fax (Credit card or Phone (Credit card only) Mail - Attn: Registrar Visit us at Purchase Order) Monday - Friday Contemporary Forumswww.ContemporaryForums.com (800) 329-9923 (800) 377-7707 6377 Clark Avenue, Ste. 200 24 hours a day 8am - 5pm, Pacific Time Dublin, CA 94568 6 Visit us at www.ContemporaryForums.com to register today • Follow us on Facebook and Twitter (#HTPC12)
  7. 7. Hotel Accommodations Travel Discounts The conference will be held at the Snow King Resort, Contemporary Forums has a special discount 400 East Snow King Avenue, Jackson Hole, WY 83001. agreement with United Airlines unavailable to the general public. To obtain these special A limited block of rooms is being held for you and conference fares call the Special Meeting your guests at special group rates which will be in effect, Desk at (800) 521-4041, Account Code 510CW. Ticketing based on room availability, from July 27 to August 2. and payment can be done directly by you or through your The discounted room rate may be available before and travel agent. To ensure the best flights and times, since after the conference for those wishing to extend their seats are limited, make your reservations early. Fares are stay. Please inquire when making your hotel reservation. guaranteed at the time of the ticket purchase. WARNING! The hotel room release date is June 27, 2012. In the past, rooms and condos have sold out Hertz is the official car rental agency as early as four weeks before the hotel room block for the conference. Special rates will release date, so make your reservations NOW. The be in effect throughout the conference as well as one rates listed below are available for reservations made week before and after. For special rates, call HERTZ at before June 27 or until the room block is full, whichever (800) 654-2240 and refer to Contemporary Forums plus the comes first. To have access to the reduced rates, you conference discount code CV#03000259. must make your reservations before June 27. Call For additional travel options, visit www.ContemporaryForums.com the hotel for availability and rates after this date. Rates: $175 single/double CONTEMPORARY FORUMS (Rates are per room and subject to prevailing state and local taxes.) 2012 CONFERENCE CALENDAR A limited number of condominiums, adjacent to the hotel, (Partial listing) are available. All units except studios have kitchens and can sleep up to 10 people as listed below. PLEASE NOTE: Release date for condos is June 27, 2012. Advances In Health Care for Women Over 40 Las Vegas, NV • May 17-19 Rates per day: Adolescent Health Care $215 – studio (2 persons) San Francisco, CA • May 31 - June 2 $225 – one bedroom (4 persons) Office Gynecology $325 – two bedrooms (6-8 persons) Snowmass, CO • August 5-8 $445 – four bedrooms (8-10 persons) Pharmacology for Advanced Practice Clinicians (Rates are per condo and subject to prevailing state and local taxes.) San Francisco, CA • September 10-16 For room reservations, call (800) 522-KING (5464) and Washington, DC • October 8-14 Las Vegas, NV • November 5-11 inform them that you are attending the Contemporary Forums’ conference, Hot Topics In Primary Care. Ambulatory OB/GYN Nursing Request a confirmation number and written confirmation Boston, MA • September 27-29 of your reservation. Contraceptive Technology: Quest for Excellence Atlanta, GA • November 1-3 Contact the hotel regarding cancellation policy. For arrivals after 3 p.m., call the hotel on the day of travel to For complete conference information, visit www.ContemporaryForums.com, call toll-free at (800) 377-7707 or email:info@cforums.com. reconfirm reservations. Contemporary Forums is a division of American Career College. For additional hotel information, call the Snow King Resort at (307) 733-5200. Online CE Library Earn CE Credit Online POLICY IN ACTION Contemporary Forums Online CE Library is your on-demand resource for quality accredited healthcare continuing education. The Library contains over 1,200 Look for the Hot Topics in Primary Care article topics in a variety of clinical areas. in JNP: Journal for Nurse Practitioners, the official publication of the American College of Nurse Online CE Library Group Access Programs: Practitioners (ACNP), www.npjournal.org. ACNP is Hospitals and healthcare facilities can provide ensuring a solid policy and regulatory accredited continuing education to foundation that enables Nurse meet staff needs. Practitioners to continue providing To request group discount accessible, high quality pricing and details, healthcare. visit onlineCElibrary.com Go to www.acnpweb.org or call (925) 361-4811. to join today! OnlineCELibrary.com A Leader in Quality Continuing Education for Healthcare Professionals for 30 years 7
  8. 8. Please Post Prominently or Forward to a Colleague if Unable to Attend U.S. POSTAGE Contemporary PRSRT STDRegistration Form: Hot Topics in Primary Care Forums PAIDSend this form with full payment (U.S. Funds) to:Contemporary Forums, Attn: Registrar, 6377 Clark Avenue, Suite 200, Dublin, CA 94568Fax (800) 329-9923, Phone (800) 377-7707, or visit www.ContemporaryForums.comREGISTRATION INFORMATION (Please Print Clearly)*Name, License/Degrees, Place of Employment, City, State appear on your badge Please share with your colleagues*First Name Social Security # (Last 4 Digits)*Last Name *License/Degrees*Place of Employment*City *State*Attendee’s E-mail For confirmation, receipt, and provide your best email address as some emails are yourCertificate of Attendance. Please print clearly access to presentation slides prior to conference, and tofiltered and blocked. 6377 Clark Avenue, Ste. 200Home Address Contemporary ForumsCity State Zip Dublin, CA 94568 PDFDaytime Phone(s) Code: CONCURRENT SESSIONS SELECTIONPlease check one of the Session numbers in each time period. Sessions are limitedin size and assignments are made in the order received.Tuesday, July 31 (See page 5) PAYMENT SUMMARY #0829128:00 a.m.  11  12 Early Fee Postmark Deadline: June 189:15 a.m.  21  2210:45 a.m.  31  3212:00 p.m.  41  42 Conference Tuition $PROFESSIONAL PROFILEChoose ONE category in each section that best applies to you. If you have multiple Group Discount (See page 6) -$roles, select the one that occupies the majority of your time. Use “Other” only if none (Registration forms must be sent in together)of the choices apply to you.1. SPECIALTY 2. LICENSE/PROFESSION Adult Health  CNM/NM TOTAL PAYMENT ENCLOSED $ Family Practice/Primary Care  FNP/ANP Geriatrics  MD/DO Internal Medicine  NP - Women’s Health  Check/Money Order Payable to Contemporary Forums Nurse-Midwifery  PA/PA-C Women’s Health  RN/RNC Other:_________________  Other:_________________ OFFICE USE ONLY: C_________ D _________ E _________ Credit Card #3. CLINICAL SETTING College Health Service HMO Exp. Date Hospital-Based Clinic Hospital Inpatient Military Clinic/Hospital Print Cardholder’s Name Multi-Specialty Group Physician Office Planned Parenthood Billing Address Primary Care Clinic/Office Private Practice Public Health/Community Clinic City State Zip Rural Health Center University/Academia Other:_________________ Payer EmailWe collect this data in order to provide you with information aboutContemporary Forums, conferences, and the Online CE Library. If youprefer not to receive further information, please see our Privacy Statement Payer Phone #at www.ContemporaryForums.com.

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